2. OxyContin, Vicodin, and Heroin Abuse: What's a Clinician to Do? Peter A. DeMaria, Jr., M.D., FASAM Tuttleman Counseling Services Temple University Clinical Associate Professor of Psychiatry Temple University School of Medicine

3. Disclosures Dr. DeMaria serves as a treatment advocate for Reckitt-Benckiser Pharmaceutical Generic versus Trade drug names Off-label use of medication

4. College Student Developmental Stage Invincible Subject to peer pressure Risk-taking Want to be independent ADOLESCENCE

5. Some Factors Affecting Drug Experimentation/Continued Use/Addiction Genetics Peer Pressure Stress Availability Trauma/abuse Curiosity Boredom Psychiatric problems

6. The Life History of A Substance User Abstinence Experimentation Abuse Dependence Sobriety Recovery Abstinence Relapse to Use

7. Core Alcohol & Drug Survey-2005 (A sample of 33,379 undergraduate students from about 53 colleges in the United States) 30 Day Prevalence Rate by Drug Type

8. College Student Opioid Use–CORE Study YearNo. of Students No. of Colleges Annual Prevalence 30-day Prevalence 200671,1891341.3%0.6% 200533,379531.4%0.7% 200468,0001331.5%0.7% 200338,857891.7%0.8% 200254,3671251.8%0.8% 200154,4441312.1%1.0% If Temple has 33,000 students, then 429 used in the last year & 198 used in last 30 days

9. Monitoring the Future Annual Prevalence for College Students

10. Papaver somniferum (Opium poppy)

11. Patterns of Use Heroin: $10 bags – Snorted, injected, smoked – Average habit = $80-100/day Prescription Narcotics (Opioids) – Oxycodone [C-II] Percocet (~$5/pill) OxyContin (~$0.50/mg.) – Tylenol w/Codeine #3,4 (~$1-5/pill) [C-III] – Lortab/Vicodin (hydrocodone), [C-III]

13. Prescription Opioid Drugs PercocetOxyContin Vicodin Tylenol #4 w/codeine Dilaudid Lortab

14. Opioids - Intoxication/Withdrawal/Overdose Intoxication – Rush, nod, miosis, constipation Withdrawal -Craving -Anxiety -Mydriasis -Insomnia -Weakness -Diaphoresis -Yawning -Lacrimation -Myalgias/arthalgias -Diarrhea -Piloerection -Rhinorrhea -Muscle twitches Overdose – Classic triad (Miosis, Respiratory depression, Coma)

15. Cycle of Addiction Drug Use Physical dependence Withdrawal symptoms Need for drugs Obtain money for drugs Obtain drugs

16. Consequences of Addiction Inability to attend classes/do schoolwork Breakdown of relationships Decrease in self-care Inability to work Financial problems (cash flow) Illegal behavior Medical risks Psychiatric illness

17. Progression of Opioid Use Prescription Opioid Medication Snort Heroin Inject Heroin

18. Precontemplation Contemplation Preparation Action Maintenance How People Change Prochaska J, DiClemente C, Norcross J. In search of how people change: applications to addictive behaviors. Amer Psychol 47:1102-1114, 1992.

19. General Principles of Treatment Comprehensive evaluation Engagement in treatment Treatment setting Detoxification vs. maintenance Counseling (Individual, Group) Self-Help (12 step)

20. MethadoneSuboxone® Component(s)MethadoneBuprenorphine + naloxone ClassificationPure opioid agonistPartial opioid agonist + pure antagonist Prevent WDYes Cause euphoriaNo Block euphoriaYes Safe in ODLethalSafer DEA RegulationC-IIC-III AdministrationOralSublingual AvailabilitySpecialized clinicsOutpatient physicians’ offices Dosing visitDailyUp to monthly

21. Using Buprenorphine to Treat Opioid Dependent University Students: Opportunities, Successes, and Challenges. Peter A. DeMaria, Jr., M.D., FASAM Robert C. Sterling, Ph.D. Robin Risler, Psy.D. Jeremy Frank, Ph.D., CAC Journal of Addiction Medicine Available on-line: Published Ahead of Print http://journals.lww.com/journaladdictionmedicine/ toc/publishahead

22. The Temple Experience Retrospective chart review of treated students. Time period = 1/04 through 4/08 27 students inducted and treated at least 3 months Average age = 22.37 ± 2.89 years old 63% Male 85% Caucasian 97% Academic juniors or higher 41% Not involved in a relationship

23. Year in School at Presentation

24. Opioid Use at Admission – Self Report

25. Initial Urine Drug Screen

26. Population Characteristics Average length of use = 33.4 ± 28.79 months (range = 4-132 months) 56% Use drugs IV 67% Smoke tobacco 56% Dink alcohol No HIV or HCV infections Family History – Psychiatric = 52% – Drug & alcohol = 70% 59% Report a history of past addiction treatment 30% Report a legal history

27. Psychiatric Diagnosis 15/27 (55.6%) had a history of a psychiatric diagnosis

28. Treatment Characteristics Average Suboxone dose = 13.8 ± 5.69 mg (range = 4-24 mg). Well tolerated; no serious adverse events Most common side effect = constipation One student became pregnant and delivered

29. Urine Drug Screen Results N = 237 UDS, M = 8.8/student, Range = 0 - 33

30. Disposition of Admitted Patients Length of Treatment = M = 12.00 ± 11.49 months Range = 1 to 36 months

31. Treatment Received ServiceN (%)Avg. No. + SDRange Psychiatric Evaluation 27 (100%)N/A Medication Management 27 (100%)10.48 ± 9.751 - 30 Individual counseling 18 (67%)7.56 ± 5.731 - 21 Group counseling 15 (56%)8.60 ± 5.692 - 20 Self-Help9 (33%)??

32. Predicting Treatment Outcome Opioid positive UDS at follow-up – Use of heroin → (+) – Use of other substances → (+) – Time in treatment (p = 0.06) → (-) Time in treatment – No significant indicators

33. Challenges Accept the disease of addiction Commit to sobriety Acknowledge that marijuana is a drug Engage in treatment Finances Managing free time/boredom

34. Study Limitations Uncontrolled Retrospective No comparison group Small sample size Limited to one university

35. Conclusions Opioid dependent university students: Are a unique group of substance users Can be safely and effectively treated with buprenorphine in a university counseling center